Provider Demographics
NPI:1063612265
Name:MILLER, JACK M (DDS)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:MILLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12720 MEETING HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7334
Mailing Address - Country:US
Mailing Address - Phone:317-571-1900
Mailing Address - Fax:317-569-9695
Practice Address - Street 1:12720 MEETING HOUSE RD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-7334
Practice Address - Country:US
Practice Address - Phone:317-571-1900
Practice Address - Fax:317-569-9695
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009482A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist